Non-Invasive Preventive Cardiolgy Application Form



HARTFORD HOSPITAL

80 SEYMOUR ST.

P.O. BOX 5037

HARTFORD, CT 06102-5037

APPLICATION FOR APPOINTMENT

PLEASE PRINT OR TYPE

Attach recent

2x2 photograph

(required)

Residency Fellowship in the Department of

For the academic year to

Name

Last First Middle

Social Security # Date of Birth

Place of Birth Citizen of

Country

Present Address Phone

Street

City State Zip code

Name and address of person through whom I can always be contacted:

Name Phone

Street City State Zip code

PERSONAL STATEMENT: (As an attachment describe professional and personal interests, achievements, goals).

EDUCATION:

Name of College and Medical or Dental School Dates (inclusive) Degree

HOSPITAL APPOINTMENTS SINCE GRADUATION:

Position Name of Institution Dates (inclusive)

OTHER MEDICAL EXPERIENCE:

Position Place Dates (inclusive)

REFERENCES: Required (applicant must request that they be sent directly to appropriate program director).

1. Medical/Dental School Transcript

2. Medical/Dental School Dean’s Letter

3. Letters of recommendation from two supervisors (professors or chief of service).

Have you ever been on probation and/or suspended from a prior program: ___________

If yes, please explain.

______________________________________________________________________________________

______________________________________________________________________________________

ECFMG CERTIFICATION:

FOR GRADUATES OF MEDICAL SCHOOLS OUTSIDE THE USA, PUERTO RICO AND CANADA.

Attach a photocopy of the letter that provides proof of certification by ECFMG

Submission of your ECFMG certificate is required for appointment.

VISA INFORMATION:

IF NOT A US CITIZEN PLEASE IDENTIFY YOUR VISA STATUS BY CHECKING ONE OF THE FOLLOWING:

Permanent Resident give #

J1 Visa expiration date

Other please identify

INTERVIEW:

I am available for a personal interview on the following dates:

I am also applying to your program. My scheduled interview date is

NRMP: I (circle one) am/am not enrolled in the NRMP Match for your program(s)

Signature of Applicant Date

Dept. of Med. Ed.

hhappl96/update 02.2010

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